Diagnostic Guide – Foot Pain

Patients suffering from foot pain are often seen in physiotherapy practice. Pain may be caused by local structures within or around the foot or may be referred from other sources (such as the lower back).

One of the most common clinical presentations is the patient suffering from gradual onset heel pain (located under the heel) due to repetitive stress on the connective tissue attaching to the heel bone (plantar fascia – figure 1) during excessive weight bearing activity such as prolonged walking or jogging. This typically causes gradual degeneration and inflammation of the plantar fascia where it attaches to the heel bone and is known as Plantar Fasciitis. There are numerous other causes of foot pain, some of which present suddenly due to a specific incident, others which develop gradually over time.

Figure 1 – Relevant Anatomy for Plantar Fasciitis

Below are some of the more common causes of foot pain with a brief description of each condition to aid diagnosis. Conditions have been organised according to sudden or gradual onset and common or less common conditions for ease of use.

Find out what may be causing your foot pain:

Sudden Onset Foot Pain – Common Injuries

Tearing of connective tissue holding the bones of the foot together (figure 2) typically following a fall or twisted foot. Associated with pain on firmly touching the affected joint and often swelling.

Figure 2 – Sprained Foot Anatomy

Fat Pad Contusion

Bruising of the fat pad located under the heel bone (calcaneus – figure 3) usually due to a fall onto the heels from a height. Associated with pain on weight bearing through the heel bone and on firmly touching the affected region.

Tearing of the connective tissue forming the arch of the foot usually where it attaches to the heel bone (Plantar Fascia – Figure 1). Associated with pain or ache under the heel and into the inner sole of the foot and tenderness on firmly touching the plantar fascia.

Tearing of connective tissue holding the bones of the toe together (figure 4) typically following excessive bending of the joint. Associated with pain on firmly touching the affected joint and often swelling.

Figure 4 – Sprained Toe Anatomy

Subungual Hematoma

Pain arising from bleeding under the toenails usually due to direct trauma or repetitive pressure from footwear.

Fracture of the 5th metatarsal bone of the foot (figure 5) usually due to traumatic forces such as a rolled ankle. Associated with severe foot pain, swelling and tenderness on firmly touching the affected region of the bone.

Figure 5 – Relevant Anatomy for a 5th Metatarsal Fracture

Referred Foot Pain

Pain referred into the foot from another source such as the lower back, frequently associated with symptoms above the foot (such as the buttock, thigh or lower leg) and in the referring area (e.g. lower back pain / stiffness). Typically associated with tenderness on firmly touching the region responsible for the referred pain and / or loss of movement in that region. Sometimes in association with pins and needles or numbness.

Less Common Sudden Onset Injuries

Fracture of the heel bone of the foot (calcaneus – figure 3) usually due to traumatic weight bearing forces such as landing on the heel from a height. Associated with severe foot pain, swelling and tenderness on firmly touching the affected region of the bone.

Partial dislocation of the cuboid bone located at the outer aspect of the mid foot (figure 5) typically following a rolled ankle or due to repetitive forces. Symptoms typically include pain or ache in the outer aspect of the mid foot or ankle and pain on firmly touching the affected bone.

Entrapment of the nerve located at the inner aspect of the ankle causing pain radiating into the arch of the foot, heel and occasionally toes. Often associated with pins and needles or numbness and tenderness on firmly touching the tarsal tunnel region (figure 6).

Figure 6 – Anatomy of Tarsal Tunnel Syndrome

Gradual Onset Foot Pain – Common Injuries

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Less Common Gradual Onset Injuries

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Diagnosis of foot pain

A thorough subjective and objective examination from a physiotherapist is usually sufficient to diagnose the cause of foot pain. Investigations such as an X-ray, ultrasound, MRI, CT scan or nerve conduction studies are often required to confirm diagnosis and rule out other injuries.